Find your risk factors Take the quiz to determine your risk for surgical complications Take the quiz below to find your potential surgical risk complications. Answer each question as best as you can, and at the end we will provide you with all the necessary resources and information needed to mitigate your unique risk factorsPlease enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone NumberAgeGenderMaleFemalePrefer not to sayOther:What type of surgery are you having? *What is the date of your surgery?Height (feet, inches) *Weight (pounds) *Have you had the COVID-19 virus infection within in the last 7-8 weeks? *YesNoUnsureCOVID-19 Testing: It is critical that you don’t have the COVID-19 virus if you are having surgery. Surgical patients with COVID-19 infections have more complications after surgery and are more likely to die after surgery.Have you been vaccinated for COVID-19? *YesNoCOVID-19 Testing: If you have not been vaccinated, get tested for COVID-19. It is critical that you don’t have the COVID-19 virus if you are having surgery. Surgical patients with COVID-19 infections have more complications after surgery and are more likely to die after surgery.Do you have a Penicillin Allergy? *YesNoUnsureMany people think they have a penicillin allergy but about 8 people out of 10 people can still take penicillin because it has gone away over time or it is a very mild allergy or sensitivity. Often, penicillin type antibiotics are the best antibiotics and if you can’t take penicillin, you may not be getting the best antibiotic for your surgery.If yes or maybe, what were the symptoms of the allergic reaction? (Select all that apply)RashHivesThroat felt like it was closingWheezingI'm not sure. I had the allergic reaction many years ago (i.e in childhood)Do you smoke or use any tobacco or nicotine delivery product? *YesNoIf yes, what products do you use?CigarettesVapingChewing tobaccoHave you lost 8 pounds unintentionally in the last 3 months? *YesNoUnsureIn the last week, have you eaten less than half of what’s on your plate? *YesNoIs it hard to swallow food? *YesNoHave you ever been diagnosed with Obstructive Sleep Apnea? *YesNoUnsureIf you have sleep apnea, you may wake up at night and be tired during the day. You are also at risk for infections after surgery. If yes, do you use CPAP?YesNoI'm supposed to but I don't use itIf no or unsure, do you snore? *YesNoUnsureDo you wake up at night gasping for breath? *YesNoUnsureAre you often sleepy during the day? *YesNoIs your neck more than 15 inches around if you are female or 16 inches if you are male? *YesNoSubmit
